Serum progesterone and human chorionic gonadotropin in very early pregnancy: implications for clinical management

We studied beta-human chorionic gonadotropin (beta-HCG) and progesterone (P) in maternal serum in 71 patients with a positive urine pregnancy test with a threshold of 50 U HCG/liter urine and an ultrasound examination without demonstrable fetal heart beat. Patients were divided into three groups: ongoing intra-uterine pregnancy of more than 12 weeks duration (n = 23), ectopic pregnancy (n = 14), and abnormal intra-uterine pregnancy (blighted ovum, early spontaneous abortion) resulting in dilatation and curettage (n = 34). We found that both beta-HCG and progesterone levels were significantly lower in abnormal pregnancies but that there was less overlap between the progesterone values in normal, ectopic and abnormal pregnancy as compared to beta-HCG levels. There was a positive correlation between beta-HCG levels less than 5000 mU/ml and serum progesterone in ectopic pregnancies but not in normal or abnormal intra-uterine pregnancies. The size of the gestational sac correlated with serum beta-HCG levels but not with serum progesterone levels in normal intra-uterine pregnancies. We conclude that serum progesterone levels (cut-off point 15 ng/ml) in very early pregnancy can be helpful to differentiate between normal intra-uterine pregnancy and abnormal intra-uterine or ectopic pregnancy.     

Combined pelvic sonography and serum beta hCG, versus laparoscopy for the diagnosis of stable patient suspected of ectopic pregnancy

The role of sonography in stable patients suspected of ectopic pregnancy is to establish the diagnosis using positive, suggestive or negative signs. Establishing whether or not intrauterine gestation is present is crucial, as is the detection of any extrauterine abnormality. Sonography may be normal in ectopic pregnancy or when it is not abnormal findings are frequently nonspecific. Therefore, the sonographic results must be correlated and integrated with the clinical history and findings as well as with other diagnostic procedures. The combination of ultrasound scanning with beta hCG was found highly contributory to the determination of the existence of an ectopic pregnancy. Understanding the objectives and limitations of each diagnostic test involved is essential for logical and optimal sequences of diagnostic procedures to be employed in patient management. During a twenty-month period, 138 patients were examined due to clinical suspicion of "sub-acute" ectopic pregnancy. Sixty-one patients were managed according to a non-invasive protocol composed of: a) ultrasound scanning alone and b) ultrasound scanning combined with serum beta subunit hCG. Ultrasonograms for ectopic pregnancy diagnosis were coded: positive (fluid in cul-de-sac or extrauterine sac); suggestive empty uterus, adnexal mass and pseudo-gestational sac) and negative (intrauterine gestational sac and normal pelvis). Surgical procedure was carried out immediately on nine patients with positive signs; all of them had ectopics. Suggestive signs were found in twenty-two patients. beta subunit hCG was determined prior to interventive procedure; ectopic pregnancy was revealed in eighteen of them. Among thirty patients with negative signs, only two patients (7% of this sub-group or 3.5% of the general group) had ectopics.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Prospective Study of βHCG Radioimmunoassay in the Diagnosis of Ectopic and Other Complicated Early Pregnancies

Summary: The β-subunit of chorionic gonadotrophin (/JHCG) was measured by radioimmunoassay in the serum of 190 consecutive patients admitted to hospital with the suspicion of ectopic pregnancy. The detection limit was set at 1 ng/ml. A urine sample was also taken for pregnancy testing on admission. A positive serum βHCG result was obtained in 36 patients (19%); pregnancy was confirmed in 32 (ectopic pregnancy 14, abortion 8, continuing normal pregnancy 7, retained products 3), giving a predictive value of 89%. There was poor correlation between serum and urine results. The serum levels were low in patients who subsequently aborted, intermediate in those with ectopic pregnancy and within the normal range in patients in whom the pregnancy continued normally. The high predictive value of the test should identify the patients for further investigation, thus avoiding unnecessary operative procedures and prolonged hospital stay.     

Serum Progesterone and Human Chorionic Gonadotrophin Measurements in the Evaluation of Ectopic Pregnancy

Summary: We evaluated the clinical usefulness of measuring the serum concentrations of human chorionic gonadotrophin (HCG) and progesterone to distinguish between early viable and nonviable pregnancies. We investigated 110 women witfi clinical symptoms of abnormal pregnancy. A single HCG measurement did not clearly distinguish between ectopic and failing intrauterine pregnancies; an HCG value below 3,000 IU/L, together with a serum progesterone below 40 nmol/L, predicted abnormal pregnancy outcome in 97% of women (positive predictive value: 91%; negative predictive value: 95%). Serum HCG values above 3,000 IU/L or progesterones above 40 nmol/L, discriminated between an ongoing pregnancy and an abnormal pregnancy in 87% women (positive predictive value: 95%; negative predictive value: 91%) and provided reassurance of an ongoing pregnancy. Our results suggest that a combination of serum progesterone and HCG measurements provide clinically useful biochemical information which enhances the prediction of pregnancy outcome.     

Monitoring Early Pregnancy with Transvaginal Ultrasound and Choriogonadotrophin Levels

Serum human chorionic gonadotrophin levels were correlated with gestational sac size detected by transvaginal ultrasound in a series of 178 women undergoing in vitro fertilization. The improved resolution of transvaginal ultrasound enables pregnancy to be detected between 17 and 20 days post-ovum retrieval, when HCG levels were greater than an average threshold level of 1,300 IU/L. The lower HCG discriminatory zone enables improved evaluation of ectopic pregnancies. Also, higher HCG titres observed in multiple pregnancies enable estimation of implantation rates when more than one embryo is transferred.     

Chronic Ectopic Pregnancy: A Clinical Analysis of 62 Cases

Chronic ectopic pregnancy is a form of tubal pregnancy in which salient minor ruptures or abortions of an ectopic pregnancy, instead of a single episode of bleeding, incites an inflammatory response often leading to the formation of a pelvic mass. Its clinical features are often confusing, and laboratory evaluations are often misleading. Surgery for chronic ectopic pregnancy is frequently difficult since chronic inflammatory changes and adhesions distort the normal anatomy. In the present retrospective study, its incidence was found to be 20.3% (n=62) in a series of 305 ectopic pregnancies. A pelvic mass of varying sonographic appearance, mostly with a nonhomogenous echo pattern, was demonstrated in all 55 patients in whom transvaginal sonographic evaluation was performed preoperatively. Although most of the patients [91.9% (n=57)] had a positive serum beta HCG value, 5 patients had a negative test value. Laparotomy resulted in 40 salpingectomies, 19 salpingo-oophorectomies, and 3 total abdominal hysterectomies with salpingo-oophorec-tomies. One patient had an incidental cystotomy and 2 an incidental colotomy. We conclude that chronic ectopic pregnancy is not rare, although little is mentioned about it as a clinical entity in the gynaecological literature. With increased awareness of its mildly symptomatic and protracted clinical course, and with proper interpretation of laboratory evaluations, a preoperative diagnosis can be made in the majority of the cases.     

Pregnancy of unknown location

All women with a positive pregnancy test who do not have a pregnancy visualised on transvaginal ultrasound, whether it is an intra-uterine pregnancy or an ectopic pregnancy, should be classified as having a ‘pregnancy of unknown location’ (PUL). Expectant management of haemodynamically stable asymptomatic women with a PUL has been shown to be safe. Serum human chorionic gonadotrophin levels, serum progesterone levels and mathematical models all have a role in the prediction of PUL outcome, which includes: a failing PUL, an intra-uterine pregnancy and an ectopic pregnancy. Surgical intervention in the form of diagnostic laparoscopy or uterine curettage does not have a role in the routine management of women with a PUL. This review article discusses the various aspects of management of women with a PUL.     

异位妊娠他科误诊致失血性休克临床分析

目的探讨异位妊娠他科误诊原因，减少误诊率。方法回顾性分析我院2000年1月-2005年6月收治435例异位妊娠中9例因临床表现异常首诊到内外科室就诊，分析异常临床表现及原因。结果2例腹泻伴下腹隐痛于肠道门诊就诊，2例发热、呕吐、下腹痛于内科就诊，3例胃痛伴呕吐及上腹痛伴呕吐于外科就诊，2例晕厥腹痛于急诊科就诊，经对症处理，最短5h、最长72h内出现休克症状而请妇科会诊，后诊断异位妊娠、失血性休克，急诊手术、积极抢救转危为安。结论生育期妇女要考虑妇科疾患，特别是异位妊娠，常规查尿HCG、盆腔B超可得到及时诊断。     

Decidual cast mimicking an intrauterine gestational sac and fetal pole in a patient with ectopic pregnancy. A case report

In a case of ectopic pregnancy, ultrasound findings showed a pseudogestational sac in the uterus containing debris that mimicked a fetal pole. Ultrasonography done one week before had revealed no intrauterine gestational sac. The progression in one week of an "empty" uterus to a seven-week-sized intrauterine gestational sac with the appearance of a fetal pole without a heartbeat should suggest to the sonographer the possibility of a pseudosac and ectopic pregnancy.     

Emergency Serum and Urine HCG Analyses with the ''Tandem ICON'' Procedure

A comparison between new urine and serum enzyme immunoassay techniques and existing serum radioimmunoassay techniques for the detection of HCG in the diagnosis of ectopic and early intrauterine pregnancy was undertaken. Urine HCG estimations by enzyme immunoassay were not found to be adequate for the exclusion of ectopic pregnancy due to a false negative rate of 12.5% (2 of 16 patients). Serum HCG estimations by enzyme immunoassay were found to compare favourably with radioimmunoassay techniques in the detection of HCG in both ectopic and early intrauterine pregnancy.     

Suspected ectopic pregnancy: ultrasound findings and hCG levels assessed by an immunofluorometric assay

One hundred suspected ectopic pregnancies were assessed by ultrasound on the basis of the following criteria: (A) viable intrauterine fetus, intrauterine pregnancy is certain; (B) intrauterine double sac or eccentric ring, intrauterine pregnancy is probable; (C) empty uterus or central ring but no adnexal mass or cul-de-sac fluid, ectopic pregnancy is possible; (D) empty uterus or central ring and an adnexal mass or cul-de-sac fluid, ectopic pregnancy is probable; (E) viable ectopic fetus, ectopic pregnancy is certain. Serum human chorionic gonadotrophin (S-hCG) was detected by an immunofluorometric assay (sensitivity 0.2 i.u./l, cut-off level 10 i.u./l). All the 51 patients in groups A and B had an intrauterine pregnancy. Normal gestational sacs were found also at S-hCG levels of less than 3600 i.u./l, the lowest level being 894 i.u./l. Ectopic pregnancy was confirmed in 29 of the 30 women in groups D and E. In the 19 women categorized into group C serial hCG assay and repeated sonography diagnosed ectopic pregnancy in 12 and miscarriage of an intrauterine pregnancy in the other seven. Ectopic pregnancy was always found when no gestational sac was seen by sonography and the hCG level was greater than 1000 i.u./l.     

Transvaginal Ultrasonographic Imaging of Ectopic Pregnancy

A 35-year-old Chinese women admitted to the hospital with lower abdominal pain was diagnosed as being pregnant by a urinary pregnancy test. However, she gave a past history of postpartum sterilization by tubal ligation after her last delivery. Laparotomy was performed immediately and a right tubal pregnancy was confirmed. Ultrasound scanning was performed to discover whether or not an ectopic pregnancy existed. However, some ultrasound requires the demonstration of a live fetus within the gestational sac living outside the uterus, and a distended bladder. Transabdominal ultrasound scanning works well when trying to detect intrauterine rather than extrauterine pregnancies. Transvaginal ultrasound has enabled better evaluation of the uterus and the cul-de-sac.     

beta-Subunit of human chorionic gonadotropin, ultrasound, and ectopic pregnancy: a prospective study

This prospective study shows that the beta-subunit of human chorionic gonadotropin (beta-hCG) "screen" and ultrasound provide for nearly 100% clinical accuracy in diagnosing ectopic pregnancy in suspected cases. During the 14 months from February, 1981, to April, 1982, 81 consecutive patients believed to have ectopic pregnancies were screened. Fifty-six had a negative beta-hCG screen, thus ruling out early pregnancy complications. No false negative results were found. Twenty-seven patients had a positive screen, and 16 of these had an ectopic pregnancy. Twenty of the 27 patients with a positive beta-hCG screen underwent pelvic ultrasound examination. All of those with a positive beta-hCG screen and no intrauterine pregnancy on ultrasound had ectopic pregnancies. With the use of these clinical aids, morbidity and tubal damage are reduced because delay in operating upon those with ectopic pregnancy is avoided. Unnecessary operation is avoided in those patients who do not have an ectopic pregnancy.     

Suspected ectopic pregnancy: ultrasound findings and hCG levels assessed by an immunofluorometric assay

Summary. One hundred suspected ectopic pregnancies were assessed by ultrasound on the basis of the following criteria: (A) viable intrautcrine fetus, intrauterine pregnancy is certain; (B) intrauterine double sac or eccentric ring, intrauterine pregnancy is probable; (C) empty uterus or central ring but no adnexal mass or cul-de-sac fluid, ectopic pregnancy is possible; (D) empty uterus or central ring and an adnexal mass or cul-de-sac fluid, ectopic pregnancy is probable; (E) viable ectopic fetus, ectopic pregnancy is certain. Serum human chorionic gonadotrophin (S-hCG) was detected by an immunofluorometric assay (sensitivity 0.2 i.u./l, cut-off level 10 i.u./l). All the 51 patients in groups A and B had an intrauterine pregnancy. Normal gestational sacs were found also at S-hCG levels of <3600 i.u./l, the lowest level being 894 i.u./l. Ectopic pregnancy was confirmed in 29 of the 30 women in groups D and E. In the 19 women categorized into group C serial hCG assay and repeated sonography diagnosed ectopic pregnancy in 12 and miscarriage of an intrauterine pregnancy in the other seven. Ectopic pregnancy was always found when no gestational sac was seen by sonography and the hCG level was > 1000 i.u./l.     

输卵管妊娠治疗现状与趋势

由于定量测定 HCG水平和阴道超声的应用 ,大约 80 %异位妊娠可以在破裂前得到早期诊断 ,因此 ,治疗倾向于保守性。甲氨蝶呤 (MTX) 1mg/ m2 单次肌内注射总成功率达 88% ,对大约 4 0 %患者可作为首选方案。多次注射方案成功率略高于单次注射 ,但副反应发生率明显升高。腹腔镜下输卵管线形切开造口术 (开窗术 )已成为治疗输卵管妊娠的标准保守性手术。若对侧输卵管异常 ,患侧输卵管行保守性治疗虽稍增加重复异位妊娠的发病率 ,但在一定程度上也能提高宫内孕率     

A sensitive urine pregnancy test as an aid in the diagnosis of ectopic pregnancy

A highly sensitive 2-hour tube test for the detection of human chorionic gonadotropin (hCG) in urine was compared with the more resource-demanding radioimmunoassay for hCG in serum as an aid in the diagnosis of ectopic pregnancy. In a first series of 107 patients with the possibility of ectopic pregnancy, the urine test was positive in 31 patients, including all 15 patients shown to have an ectopic pregnancy. In a second series of 113 consecutive patients with ectopic pregnancy, the highly sensitive test was performed in 94 patients. It was positive in 90 (96%). The median time of amenorrhea at diagnosis was 7 weeks, and only 15 patients suffered a rupture of the fallopian tube. A highly sensitive urinary test for hCG is recommended as a screening method for patients giving even the smallest indication of ectopic pregnancy.     

Serial Human Chorionic Gonadotrophin Determination in the Diagnosis of Ectopic Pregnancy

Summary: Serial human chorionic gonadotrophin (HCG) determinations were made in 21 patients with ectopic pregnancy (EUP) and in 29 patients with early intrauterine pregnancy (IUP) to examine the increase in HCG values. The median slope of the HCG rise for the patients with EUP was 116 IU/1/2 days and 4,220 IU/1/2 days in patients with IUP. The slopes were significantly different (p < 0.05). Using a discrimination limit of 980 IU/1/2 days, the predictive value of a slope below this limit was 90% in EUP compared to the control group of intrauterine pregnancies. Determination of the slope of HCG rise may be of value in early recognition of ectopic pregnancy in patients with increasing HCG levels below the ultrasonographic discriminatory zone. An international agreement on discrimination limits and unity of HCG algorithms is suggested.     

Ultrasound criteria for diagnosis of early pregnancy failure and ectopic pregnancy

Early pregnancy failure and ectopic pregnancy are common clinical diagnoses for which ultrasound can provide useful information. This review explores the use of ultrasound to diagnose early pregnancy failure and ectopic pregnancy. By documenting the developmental milestones of early normal pregnancy using ultrasound, clinicians can distinguish normal from abnormal intrauterine pregnancies. An early pregnancy failure can be diagnosed by the absence of a visible yolk sac with a mean sac diameter of 13 mm; the absence of a visible embryo with a mean sac diameter of 20 [corrected] mm; the absence of cardiac motion with an embryo measuring 5 mm or more in maximal length; or the presence of an empty amnion. In most settings, documentation of a normal intrauterine pregnancy effectively eliminates the possibility of ectopic pregnancy. The presence of an adnexal mass in the absence of an intrauterine gestational sac may indicate an ectopic pregnancy.     

Reliability of transvaginal ultrasound in detecting first trimester pregnancy abnormalities

OBJECTIVE: To evaluate the reliability of transvaginal ultrasound (US) and human chorionic gonadotropin (hCG) levels in detecting early abnormalities and predicting outcome of pregnancy. PATIENTS: One hundred thirty-two patients were studied, of which 113 had an intrauterine pregnancy and 19 had an ectopic pregnancy (EP). RESULTS: In 78 with singleton normal pregnancies, US revealed a normal crown-rump length, heart motion, and hCG levels between 1,000 to 107,000 mIU/mL. Of 16 patients with small crown-rump length, heart motion present, and normal hCG levels, 6 aborted and 10 reached term. Thus, 6 of 84 (7.14%) singleton with fetal heart motion aborted. Thirteen with small crown-rump and absent heart motion also aborted. All 8 with an empty gestational sac aborted. In 8, transvaginal US detected four twins, two triplets, and two quadruplets, whereas hCG was not discriminative. Transvaginal US revealed an empty uterus in 19 patients with an EP, whereas serum hCG varied between 37 and 10,500 mIU/mL. CONCLUSION: A fetal crown-rump length compatible with gestational age and fetal heart motion seen by transvaginal US can predict a term pregnancy in greater than 90% of patients.     

Beta HCG Levels after Conservative Treatment of Ectopic Pregnancy: is a Plateau Normal?

Summary: In 32 women with unruptured tubal ectopic pregnancies we undertook conservative laparoscopic treatment [local injection of 20 mg methotrexate (n = 18), laser salpingotomy (n = 14)]. The results of serial quantitative beta HCG measurement were followed until either a negative level was reached or until rising levels necessitated alternative/additional therapy. Plateaued values of beta HCG were observed in both the successful (n = 16) and the unsuccessful cases (n = 5).
To test the hypothesis that daily variation in the assay could account for some or all of the observed plateaued results in successful cases, the sera were retested serially on the same 'run'. In only one case did laboratory variation account for the observed plateau. The clinical implications of the findings are discussed. We conclude that serially monitored beta HCG results after conservative treatment of ectopic pregnancy may show plateaued values without indicating failure of treatment.